Sample Care Area Assessment (CAA) for Nutritional Status

Resident Information:

• Name: Margaret Stevens
• ID: 569874
• Date of Assessment: YYYY-MM-DD
• Room Number: 212

Assessment Team:          

• Primary Nurse: Sarah Johnson
• MDS Coordinator: David Lee
• Registered Dietitian (RD): Emily Clark
• Physical Therapist (PT): Alex Gomez
• Geriatrician: Dr. Nathanial Smith

Care Area Assessed:

• Specify the care area: Nutritional Status and Skin Integrity

Step 1: Triggered Care Areas

• Triggered by the presence of a pressure ulcer on Margaret's left ankle, following her admission after a fall that resulted in multiple bruises, a skin tear on her right elbow, and a large laceration across her right knee.

Step 2: Review of MDS 3.0 Findings

• Margaret, 85 years old, admitted post-fall with significant skin injuries. Consumes 75% of her meals, with regular diet, and possesses her own teeth in good condition. Weighs 178.2 pounds. Recent labs indicate potential nutritional deficiencies. She has a history of osteoarthritis, moderate dementia, and falls, placing her at risk for further physical decline, depression, and impaired skin integrity.

Step 3: Detailed Assessment

• Clinical findings: Current wounds including a pressure ulcer that necessitates enhanced nutritional support for healing.
• Review of medical records: Documents her fall, the extent of her injuries, and her medical history.
• Consultations with interdisciplinary team members: Emphasizes the need for a tailored nutritional plan to support wound healing and skin integrity.
• Resident and family interviews: Highlight Margaret's previous active lifestyle and her family's concern for her current condition and desire for her to regain her health and independence.

Step 4: Problem Identification

• Identified risks include delayed wound healing due to potential nutritional deficiencies, risk of further skin injuries, and the impact of her physical condition on her overall well-being.

Step 5: Care Planning

• Goal: To improve Margaret's skin integrity and promote wound healing through optimized nutritional status and targeted dietary interventions.
• Interventions:

• • Implement a dietary supplement regimen (House Supplement TID) as advised by the RD to address and prevent nutritional deficiencies.
  • Regular RD consultations to adjust Margaret's diet and supplement plan based on her healing progress and nutritional needs.
  • Coordinate with the PT for gentle, regular exercises to improve circulation and promote overall well-being, considering her osteoarthritis and dementia.
  • Monitor Margaret's weight and nutritional intake closely, aiming to maintain her current weight and support tissue repair.
  • Engage nursing staff in implementing a comprehensive skin care routine to prevent new pressure ulcers and monitor existing wound healing.

• Responsible Staff: RD, PT, Nursing Staff, MDS Coordinator
• Timelines: Immediate start with weekly RD reviews, daily nursing observations, and monthly PT evaluations to adjust care as needed.

Step 6: Interdisciplinary Team Review

• The team collaborates on Margaret's care plan, ensuring all aspects of her nutritional needs and skin integrity are addressed comprehensively.

Step 7: Resident and Family Engagement

• Engaging Margaret and her family in the care planning process ensures they are informed and supportive of the interventions, aligning with Margaret's preferences and health goals.

Step 8: Monitoring and Reassessment

• Short-Term: Daily monitoring of skin integrity and response to the dietary supplement regimen.
• Long-Term: Ongoing assessment of Margaret's nutritional status, weight maintenance, and overall well-being to ensure continuous improvement and adjustment of care strategies.

Documentation and Signatures:

• Signature of MDS Coordinator: David Lee, Date: YYYY-MM-DD
• Signature of Primary Nurse: Sarah Johnson, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to review Margaret's progress, discuss any challenges in her nutritional and skin care management, and refine the care plan to further support her recovery and quality of life.